Failure to Follow Infection Control Practices During Catheter and Incontinence Care
Penalty
Summary
Staff failed to maintain appropriate infection control practices during and after incontinence and catheter care for a resident. During an observed catheter care procedure, two CNAs donned clean gloves and cleaned the resident's catheter tubing. Without changing gloves or performing hand hygiene, one CNA picked up clean soapy washcloths, performed perineal care, disposed of the washcloths, and touched the resident and various items in the immediate environment. The second CNA used a wet wipe to clean the resident's buttocks and removed a dirty brief, then, without changing gloves, both CNAs touched clean briefs, draw sheets, the resident's gown, multiple pillows, sheets, and the call light. Only after completing these tasks did both CNAs remove their gloves and perform hand hygiene. Interviews with both CNAs confirmed that they did not change gloves or perform hand hygiene after touching the resident's dirty catheter and before moving to clean areas or items, acknowledging that they should have done so. The Director of Nursing also stated that staff are expected to change gloves and perform hand hygiene when transitioning from dirty to clean areas during catheter care. The facility's policy on hand hygiene emphasizes the importance of changing gloves and performing hand hygiene at appropriate times to prevent infection, which was not followed in this instance.